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How many MUE’s can be billed in a day?

How many MUE’s can be billed in a day?

Both Medicare and Medicaid have national “medically unlikely edits” (MUEs) in place that are designed to automatically deny claims that exceed specific daily limits. Although these MUEs have been in place for some time, some Medicaid plans are only now beginning to implement them. MUEs should not be confused with annual utilization limits that we have seen from many commercial payers.

For many years, the MUEs were confidential and were not published. But a couple of years ago, CMS decided they should be made publically available. Although we have published them before and they have not changed, we thought this would be a good time for a reminder.

Code Description Medicare and Medicaid MUE
95004 Subcutaneous skin tests/allergenic extracts 80
95012 Expired Nitric Oxide 2
95017 Venom skin testing 27
95018 Skin testing for drugs and biologicals 19
95024 Intracutaneous tests/allergenic extracts 40
95027 Intracutaneous sequential and incremental 90
95028 Intracutaneous/allergenic extracts/delayed reaction 30
95044 Patch test 80
95076 Ingestion challenge/initial 120 minutes 1
95079 Ingestion challenge/each additional hour 2
95144 Allergy immunotherapy /single dose vials 30
95145 Venom immunotherapy/1 venom 10
95146 Venom immunotherapy/2 venoms 10
95147 Venom immunotherapy/3 venoms 10
95148 Venom immunotherapy/4 venoms 10
95149 Venom immunotherapy/5 venoms 10
95165 Allergen immunotherapy/multi-dose vials 30
95170 Allergen immunotherapy/whole body extract 10
95180 Rapid desensitization/each hour 6

 

For example, if you bill Medicare or Medicaid for more than 80 skin tests on a given day, you may receive a denial. Likewise, a claim with more than 30 doses of allergen immunotherapy (95165) may also trigger a denial. You may want to be aware of these limits when billing Medicare and Medicaid.

It is also important to remember that, for payment purposes, Medicare defines a dose of allergen immunotherapy as one cc of extract. Because Medicaid is a state program, policies vary from state to state. If your state Medicaid plan adopts the same policy on definition of a dose as Medicare, the Advocacy Council may be able to provide guidance for a discussion with Medicaid payers.

For more information on CPT 95165, join our webinar – Everything you wanted to know about 95165 – on Feb. 20 at 7:30 pm CT.

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